There is a limited role for nonsurgical management of Volkmann’s contracture. Young age of onset and mild contractures may respond in part or in full to a program of stretching and splinting. For neonatal compartment syndrome, a program of stretching prior to surgical intervention is instituted. Children less than 4 years of age will usually not tolerate splinting (Tables 1 and 2).

There is little data on the nonsurgical treatment of Volkmann’s ischemic contracture. Tsuge noted that in 27 cases of mild contracture, if a program of therapy for stretching and splinting was started within 1 month of injury, “good results can be expected” (Tsuge 1975). Initiation of nonsurgical treatment more than 1 month from the development of contracture was not often effective. No data are provided, nor does the article indicate the number of patients treated nonsurgically.

Skeletal shortening or fusions are frequently performed in conjunction with some of the soft-tissue procedures listed below.

Shortening procedures including shortening osteotomy of the radius and ulna (Rolands and Lond 1905) and proximal row carpectomy (Goldner 1975) have been used to match the skeletal length to the shortened fibrotic muscle. Shortening procedures raise concerns in children, since the forearm is already relatively shortened by the initial ischemic insult to the bone and growth plates. Further, the principal contracture is usually on the flexor surface. Shortening the forearm indiscriminately lengthens the muscle resting length of both the flexor and extensor muscles, neglecting the predominant involvement of the contracture within the flexor compartment. Bony reconstructive procedures for long-standing contractures or for distal reconstruction required for neurologic injury include wrist fusion, trapeziometacarpal joint fusion, and thumb metacarpophalangeal joint fusion. Severe progressive finger deformities can also be managed with arthrodesis in a more functional position. These are ideally done after skeletal maturity but may need to be performed earlier if there is progressive wrist flexion deformity.

Soft-tissue procedures have included excision of the infarcted muscle, fractional or z-lengthening of the affected muscles, muscle sliding operations (flexor origin muscle slide), neurolysis, tendon transfers , and functional free-tissue transfers, as well as combinations of the above procedures (Chuang 1997; Chuang et al. 1996; Eichler and Lipscomb 1967; Goldner 1975; Gulgonen 2001; Ikuta et al. 1976; Krimmer et al. 1995; Lanz and Felderhoff 2000; Reigstad and Hellum 1981; Seddon 1956, 1964; Sundararaj and Mani 1985; Tsuge 1975, 1999; Zuker 1989; Zuker and Manktelow 2007). Excision of scarred fibrotic nerves without distal function followed by nerve grafting has been described to try and establish some protective sensation in the hand (Hovius and Ultee 2000). Fixed contractures of the joints can be addressed with soft-tissue release including capsulectomy and collateral ligament recession or excision, depending on the joints involved. Fixed contracture of the joints can be surgically addressed simultaneous to management of the shortened muscle.

Our preferred methods of treatment depend on the general classification of severity of contracture, individualized to the patient presentation.

Both volar and ulnar incisions have been described for the surgical approach for a flexor pronator slide (Page 1923; Tsuge 1975). We favor the incision and technique initially described by Page (1923) with some modifications (Fig. 6). The surgical incision begins on the medial distal arm and continues along the ulnar border of the forearm all the way to the wrist. The ulnar nerve is identified and mobilized for several centimeters proximal and distal to the medial epicondyle, including proximal release at the arcade of Struthers. Four to six centimeters of intermuscular septum between the brachialis and triceps is excised to prevent kinking of the ulnar nerve after transposition. The flexor pronator mass is elevated off of the medial epicondyle, taking care to preserve the medial collateral ligament and elbow joint capsule. Inadvertent disruption of the joint capsule is repaired as needed. The origins of the flexor carpi ulnaris, flexor digitorum profundus, and flexor digitorum superficialis are mobilized off of the ulna and interosseous membrane. The dissection is carried out above the periosteum toward the radius. The common interosseous artery arises as a branch of the ulnar artery, crossing the flexor digitorum profundus, where it bifurcates into the anterior and posterior interosseous artery (Fig. 7). The posterior interosseous artery crosses to the posterior compartment at the proximal edge of the interosseous membrane. As this is the dominant blood supply to the extensor compartment, it is important to protect this branch. Working toward the radius, the origin of the flexor pollicis longus is released from proximal to distal. Special attention is needed in this area to protect the anterior interosseous nerve. Throughout the procedure, the wrist and fingers are manipulated to check whether the contracture is improving and to help localize where there is still tightness within the muscle origin. The dissection must often be carried down to the level of the wrist to release adhesions between the flexor tendons and pronator quadratus before full correction is achieved. If necessary, the carpal tunnel should be opened and tendon adhesions released in this area as well. It has been our experience that the lacertus fibrosus and superficial fascia around the antecubital fossa are often tight and a contributor to residual elbow flexion contracture. It can also tether the superficial flexors of the wrist and fingers, contributing to incomplete correction of the wrist and fingers with the muscle sliding only. Release of this fascia helps correct the deformity and also prevents median nerve compression at the level of the pronator. Slight under-correction, which can be addressed by postoperative splinting and rehabilitation, may decrease the reduction in muscle power resulting from the muscle slide. When a pronation contracture is present and not corrected by the release of the flexor pronator origin, we release the pronator quadratus from the distal ulna. Even with a complete release of both pronators and volar distal radioulnar joint capsule, complete correction of the pronation deformity may not be possible due to fibrosis and contracture of the interosseous membrane. At the completion of the muscle slide, the ulnar nerve is transposed to an anterior subcutaneous position. The hand is casted in a position of forearm supination with the wrist and fingers in full extension. Immobilization is continued for a period of six weeks to allow the flexor pronator to heal adequately to its new origin (Fig. 8, Tables 4, 5, and 6).